Week 21 - Arterial Ulcers, Gangrene, PVD, Varicose veins and venous ulcers Flashcards
what is Leriche Syndrome
occurs with occlusion in the distal aorta or proximal common iliac artery
what is the clinical triad seen in Leriche Syndrome
thigh/buttock claudication
absent femoral pulses
male impotence
what is Buerger’s test used to do
assess for peripheral arterial disease in the leg
what are the two parts to Buerger’s test
The first part involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.
The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour.
in patients with peripheral artery disease, what colour will the legs go in the second part of the Buerger’s test
blue initially, as the ischaemic tissue deoxygenates the blood
dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration
what is the dark red colour referred to as
rubor
what do leg ulcers indicate
the skin and tissues are struggling to heal due to impaired blood flow
what are arterial ulcers caused by
ischaemia secondary to an inadequate blood supply
what are the typical characteristics of arterial ulcers
Are smaller than venous ulcers
Are deeper than venous ulcers
Have well defined borders
Have a “punched-out” appearance
Occur peripherally (e.g., on the toes)
Have reduced bleeding
Are painful
what are venous ulcers caused by
impaired drainage and pooling of blood in the legs
what are the characteristics of venous ulcers
Occur after a minor injury to the leg
Are larger than arterial ulcers
Are more superficial than arterial ulcers
Have irregular, gently sloping borders
Affect the gaiter area of the leg (from the mid-calf down to the ankle)
Are less painful than arterial ulcers
Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)
what are the investigations used in PAD
ABPI
Duplex ultrasound
angiography
an ABPI above what can indicate calcification of the arteries
above 1.3 - making them difficult to compress
this is more common in diabetic patient s
what are the medical treatments for management of intermittent claudication
atorvastatin 80mg
clopidogrel 75mg once daily
naftidrofuryl oxalate
what is naftidrofuryl oxalate
5HT2 receptor antagonist that acts as a peripheral vasodilator
what are the surgical treatment options for intermittent claudication
Endovascular angioplasty and stenting
Endarterectomy – cutting the vessel open and removing the atheromatous plaque
Bypass surgery – using a graft to bypass the blockage
how is urgent revascularisation achieved in management of critical limb ischaemia
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
what does gangrene refer to
the death of the tissue, specifically due to an inadequate blood supply
what is it called when infections infect the gangrene
wet gangrene
what is phantom limb pain treated with
gabapentin
is oedema present in PVD
not commonly no
what is a very poor prognostic sign in PVD
burning pain at night, due to elevation which reduces limb perfusion, and is relieved by hanging the legs over the side of the bed
in what syndrome is erectile dysfunction seen in
Leriche syndrome
what is the difference in pain between PVD and neurogenic claudication
pain starts in calf and typically radiates up the leg in PVD and in neurogenic claudication, pain typically starts in the buttock and radiates down the leg
what should all patients with claudication be given
Statin (e.g. atorvastatin 40mg nocte) regardless of cholesterol levels
Control hypertension – for example an ACE-inhibitor (e.g. ramipril 5mg daily) or a calcium channel blocker (e.g. amlodipine 5mg daily)
β-blockers should be avoided, but are typically safe unless PAD is very severe
Antiplatelet agent – aspirin 100mg daily or clopidogrel 75mg daily – can improve claudication distance and reduce other symptoms.
what are the indications for specialist referral in PVD
lifestyle limiting claudification
pain at rest
gangrene
what is PTA
percutaneous transluminal angioplasty
useful for short lesions in big arteries
a balloon is used to widen the artery, which in some cases, may be enough on its own. in many cases, a stent is also placed
what are varicose veins
Are tortuous dilated superficial veins
Are different to reticular veins or telangiectasia
Are caused by weak vein walls causing dilation and valve incompetence
Are often symptomless
Are investigated with Doppler venous scanning.
Can be left untreated, compressed, injected or operated on
Often recur
what are the risk factors for varicose veins
↑Age
Pregnancy
↑ No. of pregnancies
Long periods of standing – e.g. occupation as a teacher, shop assistant, surgeon(!) etc
Family History
to maintain adequate venous return against gravity, what are the two mechanisms put in place
the presence of valves, which prevent back-flow of blood distally
the deep venous system is assisted by pressures generated by muscles, noticeably the calf muscles
what is thought to be the cause of varicose veins
weakness in the vein wall causes dilation of the vein
if it occurs around the valve, then the cusps of the valve will no longer meet in the middle and the valve will become incompetent, resulting in backflow of blood, and therefore inadequate drainage
what are the most common valves involved in varicose vein formation
those around the saphenofemoral junction (in the groin), however they can occur in other places for example the junction between the short saphenous vein and the popliteal vein.
what do secondary varicose veins result from
pelvis or abdominal mases, which obstruct blood from returning from the lower limbs
what are the complications of varicose veins as a result of the veins themselves
bleeding
thrombophlebitis
what are the complications of varicose veins as a result of venous hypertension
oedema
venous ulceration
pigmentation changes
lipodermatosclerosis
varicose exzema
